An Intracranial Petri Dish? Formation of Abscess in Prior Large Stroke After Decompressive Hemicraniectomy.

OBJECTIVE: Development of brain abscess after an infarction is a rare clinical condition. There have been 11 cases in the literature. Many patients were treated with potent antibiotics only and did not survive. We present 2 cases in which patients received aggressive surgical resection of brain abscess and survived. The analysis of the literature confirmed our finding that surgical intervention of brain abscess in patients after stroke is advisable.

METHODS: A 58-year-old man was transferred to our institution with left hemiparesis, hemisensory loss, neglect, and hemianopsia. The computed tomography angiography demonstrated large volume right hemispheric infarct. He underwent decompressive hemicraniectomy but developed fevers and swollen fontanelle 6 weeks later, which did not improve with antibiotics. The magnetic resonance imaging demonstrated progression of ring-enhancement of the old infarct and abscess formation was suspected. In another case, a 42-year-old woman was admitted to our institution with aphasia and weakness on the right side. The computed tomography angiography showed left middle cerebral artery territory infarction and decompressive hemicraniectomy was performed. Patient recovered well but a brain abscess was suspected during a routine preoperative computed tomography before cranioplasty.

RESULTS: In the first case, patient was then taken to the operating room for resection of the infarcted brain tissue involved. The patient's consciousness improved, and he was discharged with antibiotic treatment. The patient subsequently underwent cranioplasty with synthetic graft with no complications. In the second case, the suspected abscess was resected surgically and culture of abscess grew Pantoea agglomerans and Bacillus macerans. The patient underwent synthetic cranioplasty 1 month later and remained in good condition.

CONCLUSIONS: Secondary abscess formation after significant ischemic stroke is a rare condition that carries potential for high morbidity/mortality. The limited body of literature with the addition of our 2 cases supports aggressive management with surgical evacuation of brain abscess to increase survival.